Are We Making Any Progress in Treatment and Attitudes?

About 50 years ago (1968) in an early edition of Resident Physician, a progenitor of Psychiatric Times, Herbert Berger, MD (Chairman of the Committee on Alcoholism and Narcotic Addiction, New York State Medical Society) wrote about the “Physicians’ Retreat from Management of Addictions” and blamed physician attitudes for turning over this major medical challenge to non-medical personnel and the criminal justice system. This retreat from potential patients was not just active rejection from physicians’ offices but an omission of responsibility to counter the prevalent argument that these individuals were willfully evil rather than sick.

Berger went on to discuss the 1919 interpretation of the Harrison Act of 1915—that keeping an opioid dependent patient “comfortable by maintaining his customary [opioid] use was not a prescription, within the meaning of the law . . . .” As a result, physicians became targets for arrest and imprisonment for prescribing narcotics to control withdrawal symptoms in attempt to make their patients comfortable. Had any progress been made from 1919 to 1968, when Dr Berger wrote his appeal?

Interestingly, on this very same page of the article in 1968 was an advertisement from Smith, Kline, and French Laboratories stating in bold type, “To reduce pain—narcotics” followed on the next page by the statement, “To reduce narcotics—Thorazine.”

As some of us may remember, chlorpromazine was used for opioid withdrawal in the late 1960s through the 1980s (and even into the 1990s in some settings), when going cold turkey was the option. In fact, chlorpromazine was frequently given to opioid dependent arrestees during incarceration, although they did not like its effects. It was never FDA approved for this purpose. Other off-label medications also were used for reducing opioid withdrawal symptoms, including the use of clonidine for opioid withdrawal along with other non-opioid medications. However, off-label marketing was quite common at that time and continued with a vengeance for opioids such as oxycontin for chronic pain, with the subsequent problems and fines against manufacturers that bring us to modern day.

Overall, the two components of the Smith, Kline, and French Laboratories (and other pharmaceutical) advertising campaign were problematic. First, reducing pain was generalized to any pain, including benign chronic pain such as backaches, headaches, peripheral neuropathies, fibromyalgia pain, and other chronic pain conditions that do not benefit from long-term opioids. Second, reducing opioids was not easy and could not be simply treated with essentially aversive medications such as chlorpromazine, which did not target the underlying neurobiology driving opioid withdrawal symptoms. Thus, little progress with the pharmaceutical industry was evident in 1968, but plenty of future problems were starting, which the next 50 years—from 1968 to the present—began addressing.

Strides in clinical research

Progress has been more evident during these more recent 50 years, moving us further away from the 1919 decisions that made it illegal to provide medical help to people with an opioid addiction. While medical progress has been slow, it has been steady. In the 1970s, because of the discovery by Vincent Dole, MD, and Marie Nyswander, MD, and the efforts of the federal government led by Jerome Jaffee, MD, the national Drug Czar, the introduction of methadone maintenance provided a wide-spread agonist treatment. Parallel work led to two important milestones: naltrexone as a blocker for opioids and its evolution to an injectable long-acting formulation as well as the development of buprenorphine as a partial agonist maintenance agent. In addition, the Data2000 legislation provided more relaxed prescribing restrictions. In addition to these maintenance approaches to treatment, aids for managing the symptoms of opioid discontinuation, such as clonidine and most recently lofexidine, also became available.

We have made significant progress in moving addiction into the medical treatment area and away from the social stigma that led to widespread incarceration of those with substance use disorders. Current treatments show good efficacy for opioids and promising research is ongoing for alcohol and stimulants.

Market influences still persist

However, along with the more humane treatments for addiction, an opposing trend began from the pharmaceutical industry to increase sales of opioids for managing “insufficiently treated” chronic pain syndromes. This trend during the 1990s resulted in the lawsuits and ongoing settlements for damages that began in 2007.

We have arrived at a time for financial settlements with some of the pharmaceutical companies that derived substantial profits from what resulted in an epidemic of death and destruction as a result of opioid overuse and dependence. Based on recent court settlements of single state cases, negotiations for national settlements might reach $10 billion for each company.

In Ohio and in a recent Oklahoma case, the judge stated that one company “engaged in false and misleading marketing of both their drugs and opioids generally, and the law makes clear that such conduct is more than enough to serve as the act or omission necessary to establish the first element of Oklahoma’s public nuisance law.”